198602936-9-7-2023-28-AS-MGFS-CVFS7N-20230907133750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602936
Report Date: 09/07/2023
Date Signed: 09/07/2023 01:38:11 PM

Document Has Been Signed on 09/07/2023 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MY LADIES GUEST HOUSE		FACILITY NUMBER:	198602936
ADMINISTRATOR:	TILLMAN, GREG		FACILITY TYPE:	740
ADDRESS:	128 N FOURTH STREET		TELEPHONE:	(626) 863-6349
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY:	15	CENSUS: 7	DATE:	09/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Greg Tillman - Administrator		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Greg Tillman and explained the reason for the visit. The facility is licensed to serve 15 non-ambulatory adults over the age of 60, with an approve hospice waiver for 2 residents. The facility is in a residential neighborhood and consist of 10 bedrooms, 3 bathrooms in the common areas, rooms #1 - #6 are either single or shared rooms and Rooms #7 - #10 are all single bedrooms with a private bathroom. The Administrator's office is on the second floor, kitchen, living room, dining room, family room, garage/laundry area, a side yard, and a front yard. LPA toured the facility with Greg Tillman and observed the following: Facility is in good repair indoor and outdoor. Kitchen is clean, refrigerator and freezer are in good repair. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Sharps and medication are kept in the kitchen. Residents do not have access to the kitchen. Each resident's room (8) were observed with sufficient lighting, required furniture, and bedding supplies. Room #3 is being used by staff and room #4 is being used as a storage. Each bathroom (7) was observed in working condition, grab bars and skid mats were observed, and water temperature was tested between 110.1-118.1 degrees F., which is within the required 105-120 degrees F. Cleaning supplies are kept in a lock closet in the hallway. Additional bedding supplies were observed. First aid is available with all the required items. Living room, dining room, and family room are clean and have sufficient seating space. Motion sound detector device was observed in the front door, door going to the laundry, and gate in the side patio. Facility is currently serving 3 residents with dementia. Cameras were observed in the common areas. Carbon Monoxide/Smoke detectors were observed and in working condition. Fire extinguishers were last checked on 7/21/23. LPA checked medication and files for 5 residents. Resident #4(R4) does not have a TB test on file. LPA reviewed 4 staff files, administrator (S1) and staff #5(S5)' files were not available for review. Copies of administrator training were review. No yearly training was available for staff. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MY LADIES GUEST HOUSE	FACILITY NUMBER: 198602936
	VISIT DATE: 09/07/2023

NARRATIVE

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LPA reviewed infection control plan and obtained a copy. Emergency disaster plan (LIC610E 10/03) was reviewed. A copy of liability insurance was obtained. Last fire drill was conducted on 3/11/23.

LPA interviewed 3 staff and 3 residents.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with assistant administrator and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/07/2023 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MY LADIES GUEST HOUSE	FACILITY NUMBER: 198602936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [count] out of 2 out of 5 staff, S1 and S5 did not have a TB test available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator will obtain a copy of TB test clearance for S1 and S5 by submittted to the department by POC due date 9/21/23.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/07/2023 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MY LADIES GUEST HOUSE	FACILITY NUMBER: 198602936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in2 out 5 staff files were not available for review at the time of the visit for S1 and S5 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator will submit a copy of S1 and S5 file to the department by POC due date 9/21/23.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff did not have record of 20 hours of training for the last 12 months, S2-S5 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator will provide 20 hours of training and submit a copy of training for S2-S5 to the department by POC due date 9/21/23.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/07/2023 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MY LADIES GUEST HOUSE	FACILITY NUMBER: 198602936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 residents, R4 does not have a TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator will submit a copy of TB clearance for R4 by POC due date 9/21/23.

Type B

Section Cited

HSC

1569.695(a)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Disaster Emergency Plan LIC610E 10/03 which is not the current version which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator will submit LIC 610E version 03/19 by POC due date 9/21/23.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/07/2023 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MY LADIES GUEST HOUSE	FACILITY NUMBER: 198602936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in last fire drill was conducted on 3/11/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator will conduct an emergency drill and will submit a copy of log to the department by POC due date 9/21/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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